Second E-Conference on ABSMN ..July 2004

E-conference topic: "Improving health care delivery in Sindh"
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Dear all,

The topic for 2nd ABSMN email-conference (e-conference) is "Improving health care delivery in Sindh". To initiate the debate I am presenting some points for further dilation, brainstorming and discussion. You may also bring forward more issues and their solutions. Please keep in mind that whatever I have written here is my personal opinion which may not be correct from your perspective. The final report of this e-conference will however be based on whatever comes forward from our brainstorming discussions here on the ABSMN and will not just be merely my or other moderators' personal opinion. All moderators of ABSMN will consult with one another before final report is released. This may well serve as a kind of
policy guideline for the Sindh Health Department and, therefore, the
quality of the interventions proposed by all of you must of high quality
thoughts and be befitting in nature.

Technical note: (1) Please do not change the subject line. Just click reply
button and write your intervention. (2) Please do not quote full original
messages to which you would be replying. Just quote those lines which are
relevant.
Time frame: The e-conference will continue for about a month. So you have
plenty of time to ponder and provide workable solutions to the problems of
health care delivery in Sindh.

Let me begin the discussion with following the points:

Negligence of doctors

Every now and then we hear that some patient was not looked after properly
and that he / she was misdiagnosed or died in hospital due to carelessness
of the doctors on duty. Recently the there has been incidents in public
sector hospitals in many cities of Sindh where patients have died in this
way and their relatives have resorted to violence due to which hospital
administrations had to call police. In some incidences doctors have gone on
strike due to such an attitude of patients' relatives. Is such violence by
relatives of patients or strike by the doctors justified? Where exactly is
the fault and how can this be removed.

In one incident in Mirpurkhas, a patient died due to non-availability of
medicines in civil hospital. On enquiry it was found that there was plenty
of medicine in district's store but there was none in civil hospital's
store. The Executive District Officer (EDO) Health said that he never
received request from the Medical Superintendent of the hospital to provide
him such medicines. The MS took stand that there is no use of keeping
medicines in district store and that these should be provided to the
hospitals straight away without any requisition, etc. Whatever, the
arguments for or against, would the ABSMNers point out where lies the fault
and who exactly was responsible for death of the patient in this case. This
is just another example. In reality patients come across many such
situations almost daily. Please suggest solutions of such issues.

Non-willingness of doctors to be posted in rural areas

Government has constructed buildings of basic health units (BHUs) in almost
every Union Council of the Sindh and some rural health centers (RHCs) in
every taluka of the province. However, doctors posted there are either not
willing to work there or if posted there do not practically see the
patients. If any doctor is posted there, he (and very occasionally, she)
would first try his / her best to stop transfer through pressure on higher
officials. But if that don't succeed in this, they sacrifice some 25
percent or so of their salary, which they pay to district health office
clerks and officials and themselves live wherever they wanted to. The main
reasons cited by such doctors is that there are no facilities for them,
their salaries are inadequate, there are no medicines in BHUs / RHCs to
treat patients and also that there are no good schools where they can get
their children admitted for their education. Whatever the reason, the fact
is that due to all this the health care delivery in rural areas of Sindh is
non-existent. What should be done in this case? What incentives are needed
to be made available for the doctors to go to the rural areas and serve
poor Sindhis there?

One solution suggested sometimes back was to hand over these BHUs / RHCs to
NGOs or to private doctors on rent, etc. But in such case it may not be
possible to provide free medical care under present circumstances unless
government funds its operations (see below for more on this).

Mismanagement and maladministration

This is one of the main problem of our hospitals. The mismanagement is
result of both unawareness of management techniques and for greediness /
corruption. In one of the recent post on the ABSMN, one of its subscriber
has criticized the present MS of the Civil Hospital, Hyderabad because of
his stringent measures which include prohibition of prescribing medicines
from outside medical stores, banning the requisitioning of lab
investigations from University laboratory and appearing in person by all
employees for, say for instance, leave applications, etc. In my opinion,
though decentralization of workload is good idea, the basis of best
management practice is "be there", irrespective of the hierarchies
involved. Just by "being there", a good manager not only get first hand
info about whats going on there but is also able to nip the problems in the
bud. Personally to me, all these measures appear to be good steps, but at
the same time, questions like "What to do if there is emergency and there
are no medicines in hospital's store?" are pertinent. If all essential
medicines are made available, these steps should be welcomed and wherever
necessary suggestions with better options be provided.

The mismanagement of hospitals and provision of low quality healthcare
(often dangerous and life-taking) also result from non-existence of
research, quality assurance system, patient guidance, integrated clinical
pathways, not paying heed to patients' feedback, inefficiency of doctors
and other employees, political interference, lack of dedication of
employees and doctors, etc. Please suggest solutions of all these issues.

Funding problems

Every now and then the officials of health department blame shortage of
funds as the main cause of faulty health care delivery. In one of the
recent statement, the MS of the Civil Hospital, Hyderabad, demanded funds
from LUMHS for continuation of better health care delivery in that
hospital. According to that news item, if correct, gets about rupees
350,000,000 (to be verified) from admission fees, etc. every year. In that
news item he also threatened to stop lithotripsy and other procedures in
Urology if LUMHS did not provide funds.

Beside this the budgetary allocations from the provincial and federal
government are also blamed to be very low. However, there are also
complaints from many house officers that whatever medicines are provided by
the government are misappropriated by the administration, both in Civil
hospitals and also in District, Taluka hospitals and even in BHUs in Union
Councils.

Private practice of doctors working in public sector hospitals

One factor responsible for inadequate health care delivery in Sindh is the
private practice of the doctors who also work in public sector hospitals.
Not only the doctors of Civil Hospital ignore patients but also the doctors
who work in district and taluka hospitals as well as those who are posted
in RHCs and BHUs, tend to avoid seeing patients in government hospitals and
dispensaries and work at a nearby place privately, even during the
so-called "working hours". One reason provided by them for this practice is
that their salaries are too low and that there are no medicines in the
BHUs, RHCs, dispensaries, etc. and 'for the sake of better health care' and
"to serve" the poor, the work privately! Often it has ben seen that the
medicines provided by the government (howsoever small in quantity and low
in quality) are sold in the nearby medical stores. The instruments like
glucometers, etc. are provided by the health department but are not used in
BHUs, RHCs, etc. instead these are used in private clinics of the doctors
posted there. All this is known to the district health authorities but no
action is taken because doctors there pay 10 - 20 percent of their monthly
salaries to the district health officials, clerks, and even to EDOs.

Quote from interview of Dr Hadi Bux Laghari, in KTN interview". In this
interview he was talking about his earlier posting in Civil Hospital,
Hyderabad as MS. At the time of this interview in perhaps March 2004 he was
not the MS of the hospital.

"When hospital started working well, when good surgeries were being carried
out in the hospital, naturally their private practices were suffering.
Before me, only 15,000 surgeries were carried out in the hospital. After my
taking over of the charge, hospital started doing 35,000 surgeries. The
20,000 more surgeries performed in hospital would have gone to private
market and that was one reason of non-cooperation of doctors with me. If
you take costs of these surgeries into account you'd get the whole idea. If
one operation costs Rs 10,000, it means that the doctors' private practice
suffered loss of twenty crore rupees (Rs two hundred million) from those
20,000 surgeries carried out in public sector hospital! Definitely if they
would work perfectly in public sector hospitals, why would their patients
go to them in their private clinics? They work in this hospital in the
morning but in afternoon and later they work in their private clinics.
That is the reason they don't want to offer better services in the civil
hospital."

Why then the private practice of doctors working in a public sector
hospital shouldn't be banned?

Free medical care and health care costs Though in Pakistan, the health care delivery is free in theory, the fact is
that mostly patients pay for their investigations and treatments. Since
poverty is the major factor in Sindh, most of the poor patients cannot
afford to go to doctors (whether in public sector hospitals or in private
sector hospitals) at the initial stage of their disease and only when their
disease has progressed to advanced stage, they go to hospital for their
investigations and treatments. However by that stage many diseases, like
cancers, become untreatable or become very costly to treat. In any case its
the patient who bears the cost of treatment. Government has failed to
provide free health care delivery to common people.

When Sindh Institute of Urology and Transplantation, Karachi, (also a
public sector institute affiliated with Civil Hospital Karachi and DMC),
can provide quality health care totally free of cost to people, why is it
that the public sector hospitals in Sindh are not able to cater to the
needs of Sindhi people? If its because of the dedication of Dr Adibul
Hassan Rizvi, why we are not having such dedicated doctors and hospital
administrators in Sindh's other hospitals?

Health care financing

Since its mostly the patient who pays for his health care treatment, the
question is which mode of payment would be most appropriate for them. Some
methods are easy and affordable for public, others are difficult. These
include user fees, fee for service, government financing healthcare through
the money it receives from people in taxes, social and public insurance,
etc. If we try to evolve an indigenous system of healthcare financing, one
will find that we do not have enough information database on the basis of
which we can frame or test a model of healthcare financing. Research has
always been ignored by us. That is why our economic policies in general,
and health- economics policy, in particular, has miserably failed over the
years. Our healthcare delivery system is based on the British system model,
which primarily was government funded and meant for providing
health-services to their army, their civil servants and expatriates. Two
prevalent models of healthcare finance in the world are: (i) Bismark model
(named after Otto Van Bismark (1815-98), the Prusso-German statesman and
founder of social insurance system in Germany) and (ii) Beveridge model
(named after William Henry Beveridge, British economist (1879-1963). The
former model envisages compulsory insurance against ill-health for workers.
The latter model proposes government-funded system for full preventive and
curative treatment. This led to the formation of national health service in
Britain in 1948. In sharp contrast to these models the healthcare system of
USA is free-market based (US member of ABSMN would know this better and
expect feedback from them on this point) with minimal interference of the
government. Here competitive private insurance companies provide the
healthcare funding. The US government, however, provides a helping hand to
the poor and aged through 'Medicare' and 'Medicaid'. Hence the US system
does not provide universal coverage to its citizens and is criticized for
being inequitable, though efficient.

What kind of changes, then are needed for betterment of health care
delivery and its financing in Sindh? There are two types of reforms in the
field of health care financing based on the empirical evidence and research
elsewhere, which can be instituted in Sindh. The first type of reform we
need is 'system level changes' that include the question whether to adopt
insurance - based financing system or taxation - based system (the kind of
which is in vogue at present), or the combination of both. The other reform
which maybe needed is 'micro-level changes'. This will address the question
about the mode of payment to healthcare providers (whether our doctors, the
healthcare providers, should be salaried employees, contractors of
health-care services or should be paid on the basis of capitation and
patient lists). This is important to address complaints of doctors being
inadequately paid in the present system due to which they resort to corrupt
practices.

Whichever the mode of financing is adopted, the ultimate burden of the
increased costs will have to be borne and shared by the people themselves
at least under present circumstances where government of Pakistan keeps
health care as one of its lowest priorities and major portion of national
budget goes to defense expenditure. All these arrangements are disguised
forms of user fees. Further, by making the healthcare delivery system
efficient, this burden could be eased. If NHS type of model is adopted,
some burden on the patients does decreases as most of the health care
funding would then be provided by the government from its tax revenue (I
need feedback from UK based ABSMNers, Sohail Ansari and Mustafa Soomoro in
particular). Under present circumstances, where our priorities are only
defense of the country, increasing health care budgetary allocations can
only be made by leving extra "health tax" from the general populace. If
this shouldn't be imposed, what are the other sources of generating funds
for providing efficient free health care delivery to the people? I would
like to know the opinion of the ABSMNer on this particular point. In my
opinion, these changes in, healthcare delivery system need to be done as
part of the holistic approach. Any effort in isolation would not get the
desired results. Major factors which have increased the healthcare costs
include: (1) high cost of latest technology, (3) spread of these services
to greater proportion of the population and (3) rise in the number of
people aged under fifteen and over the age of sixty years requiring more
expensive healthcare interventions. Corruption of politicians, civil
servants, healthcare providers, the changing disease patterns (like
emergence. of HIV/AIDS), epidemic levels of Hep. B, (in future combination
of HIV/AIDS with Hep. B, C and/or TB, etc. can become a major problem),
ignorance of healthcare delivery system managers and policy makers have
also contributed to high costs of healthcare.

Same health care provider and funding agency

In this country, the provider and financier of healthcare are the same,
i.e. the government. In such a case, one cannot expect efficiency. In my
opinion, we need to separate the responsibility of healthcare provision and
funding. The government should only act as financier and provision of
healthcare should be handed over to the private sector. Private sector, not
in sense, which gets user charges from patients, but in sense that it
provides health care delivery to the people free and requisitions charges
incurred on patients health care delivery from the government. Contrary to
our perception the fact is that these days 80 to 90 per cent of curative
primary healthcare is purchased by households themselves, even in India
(World Development Report 1993). This was estimated in national health
accounts study carried out by the World Bank. Therefore, at least, the
tertiary level healthcare delivery centres should be privatized (providing
health care free to the patients and charging the costs from the
government). The government should purchase healthcare services from these
private providers for free health care delivery to the general public. This
will help in decreasing costs, as there will be competition among private
providers to get the contract for services from the government. The
government or an independent professional regulatory authority can then
dictate its terms and conditions, and award contracts to those providers
who offer maximum services per unit cost. This system would also decrease
burden of government spending on employing inefficient, salaried doctors as
well as prevent misuse of public money, as is vogue these days. For
instance, the government can award contract of health care delivery of
tertiary care hospitals to medical companies for a fixed amount. This can
be done through open auction and lowest bidding company may be awarded the
contract for a particular period, say one year. The health care company
thus awarded contract would then provide free health care to whatever
number of people it receives in the hospital, free of cost. If that company
worked well, the contract can be continued otherwise it may not be renewed
for another year and new bids may be invited. This would create a kind of
competition and costs of health care would gradually decrease and
efficiency would increase. This kind of arrangement would not be liked by
the health department employees and those who want to continue the status
quo, because if health care delivery contract is provided to some private
medical company, it will obviously employ its own human resource for the
sake of efficiency and this wouldn't be liked by the present professors,
registrars, and para-medical staff, especially those who are acting as the
'parasites' of the health department. But we have to think on the lines of
improving health care delivery to everyone, even if the doctors, as a
professional group, has to sacrifice something.


I don't want to generalizing the international experience and extrapolating
the findings of studies carried out elsewhere to our milieu as it can be
dangerous. So we need to evolve our own indigenous ways of bringing about
all these reforms and changes. In my opinion, all major policy changes must
be brought in stepladder pattern and in light of the findings our own
national health accounts studies. Cautious approach may be adopted but
without further delay in initiating reforms. Periodic national health
accounts study and analysis should be carried out to evaluate the
implications of such changes and modifications be made according to its
findings about who pays, how much and for what?

I have mainly focused on corruption of health department, mismanagement and
funding problems because I personally feel these are the main issues.
Certainly, there are many other macro and micro level issues which need to
be addressed and that's why we are having this conference. Please feel free
to suggest your interventions in detail.

Thank you,

Mir Atta M. Talpur
LMC 88
Moderator
Mirpurkhas, Sindh


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